Treating the 'Patient From Hell'

Batya Swift Yasgur, MA, LMSW

Disclosures

September 20, 2012

In This Article

Introduction

Some patients warm your heart. They help you remember why you went into medicine.

Other patients make you wish you had become anything but a physician. They yell or whine, manipulate or threaten. Some ignore their treatment plan and blame you when they don't improve; others insist they know more than you do. Some don't pay their bills, and others fail to show up for appointments.

Hard as it is to admit, you wish they'd go away.

Embarrassed About Your Negative Feelings?

"Many physicians feel they 'should' be loving and tolerant toward all patients, but that's not realistic," said Auguste Fortin, MD, Associate Professor of Medicine, Yale University School of Medicine, New Haven, Connecticut. "In every setting in life, we all get along better with some people than with others, and medicine is no exception."

Disliking a patient is not as uncommon as one might think. "In 1978, I published an article called 'Taking Care of the Hateful Patient,'"[1] said James E. Groves, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts. "It's been over 3 decades, and I'm still receiving mail, calls, and interview requests."

Although everyone has their own positive and negative traits, there are several categories of unpleasant behavior that may cast a very dark cloud over the patient visit.

The Patient With Anger Outbursts

Some patients may periodically erupt. "Anger in a patient is one of the most difficult emotions for a physician to deal with," observed Neil Baum, MD, a New Orleans-based urologist in private practice and coauthor of Marketing Your Clinical Practices: Ethically, Ethically, Effectively, Economically (Jones & Bartlett, 2009).

There are several reasons why a patient may snap at the physician. However, not every patient who displays anger has an identifiable "reason." Some people are easily irritable and don't restrain their anger in any aspect of their life. Still, it's up to the physician to diffuse or deal with that anger.

Sometimes patients become angry because they are receiving a negative diagnosis, and they lash out. "Some people react with anger when you deliver bad news, such as a terminal diagnosis," said Baum. "You have to be extraordinarily sensitive and recognize that this patient will require a lot of time and attention."

Other times, the patient's anger might be justified. Perhaps a staff member was rude to them, for example. "Acknowledge the patient's right to be upset about that situation. Ask, 'What can I do to rectify this?' Sometimes, a better formulation is, 'How can we fix this?' Using the word 'we' acknowledges that you'd like to work as a team," Dr. Baum advised.

"It helps to be very specific," Dr. Baum added. "Say, 'I'll check with my staff member and get back to you within 3 days. How can I best contact you?' This shows the patient that you're serious about investigating the complaint and you're taking definitive steps to address it."

"Follow up with a letter saying, 'Thank you for calling attention to such-and-such. I appreciate it when patients share their concerns, because it helps my practice to run more smoothly so that I can treat patients more effectively,'" Dr. Baum said. "That brings closure." And be sure to include the letter in the patient's chart, together with documentation of the complete discussion.

It's important to give time and attention to any angry patient, not only someone who has received bad news, says Dr. Baum. Don't rush through the appointment. Don't answer the door or take calls during the visit, and don't interrupt while the patient is talking. "Allowing patients to get things off their chest can ameliorate tension."

Create a conducive environment. "Don't remain standing when your patient is sitting, because that places you in a superior position, which will increase the patient's anger. Never talk to a woman who's wearing only a gown. She'll feel vulnerable, which may cause her to lash out more."

Sit directly across from the patient without barriers, such as a desk or examination table, between you. "You want to create an atmosphere suggesting that you and the patient are a team, and together you'll solve a difficult problem."

A Method for Dealing With Angry Patients

Shakaib U. Rehman, MD, Physician Manager and Professor of Medicine, Ralph H. Johnson Veterans Affairs Medical Center and Medical University of South Carolina at Charleston, and Dr. Fortin both use the mnemonic ADOBE to remember how to deal with an angry patient:

  1. Acknowledge the difficulty; for example, "I notice that whenever I speak, you interrupt and yell."

  2. Discover the meaning of the patient's behavior. "Anger is a proxy for deeper emotions such as grief or fear -- especially in men, who are often acculturated not to express these emotions directly."

  3. Recognize the opportunity for compassionate communication.

  4. Set clear boundaries if the patient is still behaving abusively -- for example, you can ask him or her to leave, or say you'll call security.

  5. Extend the system -- don't try to handle the patient alone. Get help from colleagues, staff members, nurses, or social services.

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