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

Daniel I. Krell, MD


April 10, 2013

In This Article

Dealing With Undesirable Behaviors

Here are responses that can work successfully for undesirable behaviors that do not place patients on the "difficult" end of the spectrum (which would call for more significant consequences):

Know yourself. Know your hot buttons, your style of dealing with patients, and your tolerance for various behaviors. Be honest in this assessment, and be willing to consult with another medical provider if you feel your own issues might be complicating interactions with a patient.

Step back, do a gut check, and see your feelings as a diagnostic tool. Your response to the patient is likely to be similar to the responses of others in the patient's world; find out what is driving the behavior that prompts your feelings and address it, if possible.

When reacting to a patient, consider the melody, not the lyrics. What is the overall tone of the patient's presentation (eg, anxiety, persecution, loss and depression; manipulation; abandonment; delusion; entitlement; narcissism)? By paying attention to the overall mood, rather than focusing on the patient's words or statements, you're likely to get a better picture of what he or she is really trying to communicate.

Some Reasons for Patient's Difficult Behavior

Consider medical causes. These include substance use, such as alcohol; psychiatric illness; hearing loss (which isolates people and can make them distrustful); cognitive impairment; toxins (I've encountered difficult patients with elevated lead and carbon monoxide levels); medication side effects; and central nervous system disease.

Consider "nonmedical" interventions. For example, for anxious, clingy patients with never-ending concerns, I found it useful to say something like, "You have so many concerns that we cannot do justice to them and to you in today's visit. Let's schedule visits every _____ (I usually start at every 2 weeks); we will work through your list of problems, starting with the most important. You will know that you have visits scheduled, so you don't have to worry about making an appointment for a concern. If you are doing well and feel that you do not need to see me, cancel that next appointment, knowing that you have the following appointments scheduled."

Most commonly, the patients come in for some the scheduled appointments, get the support and concern (validation) that they need, and then taper and drop the scheduled appointments, appropriately coming in as they need to. Plan to decrease the frequency of the visits (with supportive comments about getting through the patient's own problem list) when reasonable, if the patient has not decreased or stopped them.

Turn persistent noncompliance into a positive conversation. I would politely review the record of noncompliance, and then say that I might be misunderstanding what role the patient would like me to take, because all my suggestions were declined in one way or another. I would ask what they would like me to do about the issues they are raising. This avoids a compliance power struggle and often results in enlightening conversations.

I emphasized that patients ultimately own their decisions about compliance, and the consequences of those decisions; I work to make sure they have enough information and understanding about their conditions and treatments to be comfortable with their decisions. I let them know that I would continue to see them as patients even if they do not comply with my recommendations, and we will deal with whatever comes along (I often added the comment, "I'll still respect you in the morning").

If a patient doesn't take a medication because his sister says that it does not work, I respond that my (fictional) sister says it does work. I usually get a look like I'm crazy, and then we laugh.