Patients: 'Difficult,' 'Tough' or Just Misunderstood?

Daniel I. Krell, MD


April 10, 2013

In This Article


I am a family practitioner, and I've practiced in a rural health center in a medically underserved area. I've been pondering the concepts of "difficult" or "tough" patients, trying to identify what, for me, defines such patients. There is a difference in the way a physician would most effectively deal with patients depending whether they're difficult or merely in a difficult situation in life; whether they're noncompliant; or whether their behavior is unacceptable to the practice.

As a primary care physician, I usually followed my patients directly or supervised mid-level practitioners who were seeing my patients. On call, I would see my patients and those primarily cared for by my coworkers. I had the privilege of knowing my patients and their extended families very well, interacting with them for many years and under a great variety of conditions.

Many patients' concerns do not fit into and cannot be easily addressed by standard procedures. With these patients, the doctor needs to have a different perspective and use a different kind of interaction than she or he would with other patients.

I suggest using the concept of "tough or difficult situations" rather than "tough or difficult" patients -- even though their behaviors may create problems for the office staff and me. Behaviors related to the patients' situations can be addressed. In some cases, however, consistent and intense behaviors move the patients from the "tough" to the "more difficult" end of the spectrum.

Behaviors that I associate with difficult patients, and that could lead to firing a patient, include:

Recurrent no-shows, late cancellations, or chronic lateness for appointments;


Recurrent, inappropriate after-hours calls despite addressing that issue;


Inappropriately claimed disability; and

Consistently belligerent or hostile, or otherwise inappropriate, behavior toward office staff.

These behaviors differ from the undesirable behaviors we all encounter that are typically related to compliance with our recommendations: for example, medications, lifestyle and behavioral changes, follow-up appointments, and appropriately informing us of salient information.

I have heard of physicians who fire patients if they do not stop smoking, lose weight, or make lifestyle changes. I have never been tempted to do this. We are dealing with humans, after all. Their imperfections manifest in a variety of ways, and we are tasked with using our tools to address them as we feel is appropriate. Pruning noncompliant patients out of one's practice has its benefits, but more so for the medical provider than for the patients, their families, and the community in which the provider is working.