Difficult Patients: How to Deal With Them

Benjamin S. Bryner, MD

Disclosures

March 26, 2012

Question

How do I get along with a difficult patient?

Response from Benjamin S. Bryner, MD
Resident in General Surgery, University of Michigan Health System, Ann Arbor, Michigan

In Anna Karenina, Tolstoy claimed that "Happy families are all alike; every unhappy family is unhappy in its own way." Similarly, most happy patients are alike; they're contented, happy to answer questions, appreciate of their care. Probably most patients are like that. But there are a significant number of patients who aren't happy. At some point they have been derailed from their expected track of history, examination, testing, diagnosis, treatment, recovery. Maybe they're dissatisfied with their surgical outcome, or a side effect of a medication, or their perceived lack of progress. Maybe they're annoyed at the early-morning lab draws, offended by something a physician said in clinic, or they're starving and the Jell-O just isn't getting here fast enough. And maybe they'll take it out on you, the med student.

A lot has been written about getting along with difficult patients. Journals for pretty much each specialty have covered the topic. But the challenge posed by a difficult patient to a medical student is different from the challenge for a resident or supervising physician. You don't have the level of responsibility they do, but you also don't have the same experience. During my first week of clinical rotations in med school, a toothless woman told me, "You are the stupidetht person I ever met." (This was because I wasn't able to help her figure out how to turn on her own CPAP machine.) I didn't really know what to do at that point except mumble "sorry" and leave. Regardless of what it says at the top of this page, I'm no expert. It's a lifelong process, and most of us have still seen senior faculty members shaking with frustration at a particularly tough patient.

Nevertheless, here are a few suggestions:

Play up your role as a student. Say something like, "As a student, how can I learn from this experience for the future?" OK, so say it more smoothly than that, but the point is to show that you're in a nonthreatening role and are willing to listen to them.

Fix the underlying problem. This is one of those great phrases that show up in ACLS algorithms; it's a reminder to someone in a real-life situation to fix any obvious problems that the algorithm never could have predicted. It works here too. Because every unhappy patient is unhappy in his or her own way, sometimes you have to try something you haven't tried before. We had one adult patient with a history of traumatic brain injury who wasn't cooperating with our requests to eat and walk around after his operation. A nurse suggested that we try simpler food, so we asked the nutritionist to give him some of the choices from the menu from the children's hospital. After that, everything went a lot better.

Wait them out. Last year one patient's wife berated me for 15 straight minutes when I told her that we didn't know what diagnosis to give her husband. Multiple tests hadn't yet unraveled his complex condition, and she essentially told me it was my fault. It was intense anger and was directed so personally at me. From the way she was talking, it was as if I had a hand in designing the common bile duct, or it was my idea to hide so many lymph nodes in the middle of the torso. As soon as she started, though, my instinct was that she just needed to vent. I waited patiently, without interrupting. And indeed, after she had worked it out of her system, she immediately apologized. The rest of our interactions on that admission were very positive, mostly because I hadn't reacted in kind. I saw the two of them a few months later in the preoperative holding area. He was there for another biopsy, unfortunately, still waiting for a final diagnosis. Pre-op was busy, and I could have kept moving. It was tempting to just avoid the entire situation, the awkwardness of seeing a patient whom I hadn't really been able to help. But I walked over to them and they both greeted me warmly, like an old friend.

So those are 3 suggestions. I guess if you only encounter 3 difficult patients during medical school, you're all set.

There are limits to what you should tolerate, of course. Any time you're in a situation that is dangerous or potentially abusive, get out immediately and talk to a resident or supervising physician. Don't compromise the unity of the team, don't negotiate with an argumentative patient, and don't promise them anything. But there are times when you can help an unhappy patient become contented, such that you might forget that they were ever "difficult" at all.

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