The Art of Handling 'Difficult' Patients

Neil Chesanow

Disclosures

February 23, 2015

Those 'Difficult' Patients Whom You and Your Staff Dread

You know who they are: patients who are angry, disrespectful, and rude; patients who demand specific drugs or tests, even when they're not indicated; and patients who growl at everyone, act suggestively to the nurses, or ask you to submit a fraudulent bill so the insurer will cover the cost of treatment.

In a recent Medscape article, physicians discussed how they deal with the types of patients doctors dread. One suggestion, for example, is to draw boundaries with angry patients, clarifying behavior that's unacceptable and demanding respect. Many patients are unaware of how they appear to others. If this doesn't work, such patients are sometimes asked to leave the practice.

Another tack is learning how to say "no" without being negative. Apologies can also win over difficult patients. One doctor readily apologizes for things that aren't her fault: an overlong waiting room stay, a specialist referral whom the patient didn't like. "Patients are forgiving if you are seen as genuinely sorry for what happened to them, regardless of how it happened," the article pointed out.

Their strategies inspired commenters to share some pearls of wisdom.

"Rude, abusive patients need to be dealt with," an emergency physician agreed. "Professional, well-paid front office staff know how to deal with them. When you pay minimum wage for receptionist personnel, you are getting what you paid for. Patients don't come into the office because they have nothing better to do. They have a concern. If we aren't running on time, they get impatient and may pull an attitude. It's having your staff prepared to deal with attitudes that makes for a successful environment."

"My hospital department head used to make this observation," an ob/gyn recalled: "'5% of your patients cause 95% of your patient problems! Get rid of them!'"

"I handle this always in the same manner," a pulmonologist explained. "I inform the patient calmly and politely, in the presence of my office manager (sometimes I do this in writing to avoid a confrontation), that the basic ingredient in the patient/doctor relationship is trust, and that their behavior implies that they do not have trust in me as a doctor or in the practice in general. This makes it impossible for me to be their physician. I advise them to find another doctor and discharge them from the practice. I refer them to the doctor referral service at the local hospital or to their primary care physician for a referral to another physician in my specialty. Finally, I advise them that I will be available for emergencies only for 1 month after the date of my letter. I document any behavioral issues, of course. Bingo—no more bad patients and a nice and quiet practice."

"The whole notion of 'firing' a patient is an absurdity," another emergency physician contended. "In over 40 years of practice, I haven't run into a patient who isn't manageable. I make believe that every patient is wearing an invisible sign that says, 'I want to feel important.' Patient's don't want to feel as if they received the crumbs of your attention. In assembly-line medicine, docs tend to lose sight of the art of listening and encouraging communication with their patients."

"I keep seeing this advice: 'Letting the patient tell their story without interruption doesn't take that long,'" a family physician notes. "Must be from doctors who see a very different kind of patient than I do. I work on an Indian reservation. There is a very low level of medical knowledge, and it is a story-telling culture. Telling about elbow pain may eventually involve every part of the body; unrelated accidents going back to 1942; and what every cousin, doctor, nurse, and others have said to the patient in the past 6 months. I think I will continue to interrupt and guide the conversation as needed."

"Very few people are not trainable," a psychiatrist observed. "Our own dynamics tend to trip us up more than our patients do. We are usually pressured for time. We try to make things run smoothly so that our staff aren't taking the heat for our delays, but it's hard—hard not to show impatience and inadvertently inflame the situation, hard to feel compassion for someone acting like a jerk, and hard not to take a day of frustrating encounters out on the people in our lives. We fear harming a patient by missing a diagnosis, not recognizing an important drug/drug interaction, forgetting to check a lab, missing a call-back, etc, and this problematic patient causing uncomfortable delays rapidly erodes the very slim margins we deal with. But we have to do it. It is part of our roles as physician and leader to handle the situation and find an appropriate path through. That involves having clear boundaries for both patients and staff, good training for staff, and learning how to identify and manage what pushes our own buttons."

"'Physician, heal thyself' would have been a more appropriate title for this subject," a pediatrician wrote. "In 28 years of practicing primary care, I have never experienced an episode of 'shouting, name-calling, or threats.' Ever. And isn't it telling that the section titled 'Are Some Doctors Part of the Problem?' goes on to say that most of 'these' patients are frustrated or fearful, not drug addicts or personality-disordered. So it follows that if most of the patients are frustrated with their care, then it is way more than just 'some' doctors who are part of the problem. The answer to almost every situation posed is empathy. We are in a service role, doctors, and it is our privilege to care for others."

"We've all spent years perfecting our technical skills, and we have been slow to grasp the nontechnical aspects of patient care," an orthopedic surgeon reflected. "The average physician will have more than 160,000 encounters with patients. And busy physicians will perform 10,000 procedures during this same time frame. Why is it that we have worked on perfecting those technical skills? Medical school taught us to 'find it and fix it'! Come up with that differential diagnosis. There will be greater patient and physician satisfaction, however, if we incorporate the nontechnical skills of engagement, empathy, education, and enlistment when we interact with patients." 

"Lots of blaming here," a family physician pointed out. "It seems to me there is a fundamental failure in the process these days. A lack of time. As physicians we are forced by low reimbursements to schedule patients every 15 minutes, and patients are often double-booked to ensure we are 'productive.' Then, after waiting for more than 15 minutes in a waiting room crowded with others, they are given 15 minutes to explain exactly what is the most pressing problem today, while doctors type furiously into their EHR. A quick script is given to cover present symptoms, as the doc doesn't have time to really educate them on how to be healthy. Everyone walks away unhappy."

"All patients make me happy," a plastic surgeon wittily summed up, "some when they come to the office, others when they leave."

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