The challenging patient

All doctors encounter patients whom they find personally or professionally challenging. Accepting and understanding why this happens can help in the management of their care. Dr Mónica Lalanda investigates

Becoming aware that we have feelings of dislike towards some of our patients or that we find them really difficult to cope with can make us feel uncomfortable

Some of the most intrinsic feelings and inner thoughts that we have as doctors live hidden in our own personal Pandora’s boxes. There are certain things that we find difficult to acknowledge, even to ourselves. Becoming aware that we have feelings of dislike towards some of our patients or that we find them really difficult to cope with can make us feel uncomfortable. As doctors, wwe usually expect medical encounters to constitute a source of mutual satisfaction; like that of Faust, the doctor’s ideal is to “know all, love all, heal all”.

“Challenging” patients are not those with difficult medical problems; we have the knowledge, the training or the resources to deal with those issues. Such patients are those that engender in us a negative emotional response; patients who trigger strong feelings of frustration, hopelessness, exasperation, sadness or even anger.

This is all part of the daily practice of being a doctor. However, as you know, traditional medical education has in the past failed to properly prepare new doctors for dealing with such sensitive situations. As you leave medical school you might be very well prepared to manage a patient with diabetes, but totally lost in front of a diabetic patient who becomes abusive or demanding. Thankfully, the situation is improving, with effective communication skills forming an increasingly important part of undergraduate medical training.

It is interesting to notice that the literature regarding challenging patients is limited, considering the widespread nature of the problem. The way it has been handled during the years is also a significant benchmark of the evolution of the relationship between doctor and patient.

Back in 1949, the International Journal of Psychoanalysis published a paper called “Hate in the counter-transference”, written by paediatrician DW Winnicott.2 In it, he acknowledged outright hatred for some patients in certain circumstances and even murderous wishes associated with it. Later on, in 1978, James E Groves wrote extensively about these kinds of encounters in a relevant article called “Taking care of the hateful patient”, where he classifies the difficult patients into groups. Talking about a certain group of hated patients who are self-destructive, but deny all problems, Groves writes that “these patients evoke all these negative feelings, as well as malice and, at times, the secret wish that the patient will ‘die and get it over with’”.

A paternalistic approach to the patient has slowly turned into more of a partnership

Fortunately, as modern medicine evolves and a more reflective practice helps us keep the lid on our Pandora’s boxes, we can now read such extreme comments with a deeply critical eye. A paternalistic approach to the patient has slowly turned into more of a partnership, and this has also been reflected in the related literature. In previous studies and classifications, the nature of the problem always seemed to lie with the patient only; however, now it is well recognised that not only are there “difficult” patients, but as doctors we all have characteristics that may contribute to the difficulty of a consultation, and that one doctor’s list of difficult patients may not necessarily be the same as another’s.9

In addition, there is also increasing acknowledgement of the risk of doctors labelling a patient as “difficult” when in fact the difficulty may be more attributable to the challenges in their clinical management, the poor prognosis of their disease or the limitations of the system to offer appropriate support to the doctor and/or patient.

Heartsink patients exasperate, defeat and overwhelm their doctors by their behaviours

It is well accepted that encounters with challenging patients present more complex problems for those providing long-term care and, therefore, are more common in general practice. In fact, the commonly accepted term “heartsink” was coined by Tom O’Dowd, in his 1988 paper for the BMJ entitled “Five years of heartsink patients in general practice”. The term “heartsink” describes intuitive feelings of impending doom or helplessness when certain names appear in the appointment list. O’Dowd wrote that heartsink patients exasperate, defeat and overwhelm their doctors by their behaviours. They are a source of stress as they arouse negative feelings and so make the doctors involved feel unprofessional and frustrated.

Female doctors may suffer more than males in this respect as there is a common belief, on the part of both male and female patients, that being female makes you an expert on gynaecology, obstetrics, family planning, paediatrics and neurosis. Heartsink patients are also more likely to be female and therefore more likely to seek a female doctor. 8

There is no doubt that hospital doctors also meet difficult patients in their everyday practice, but these challenges are more likely to relate to managing patients with specific common presentations within their discipline. Any emergency medicine doctor can recognise the feeling of frustration at seeing a patient who has just been described by the triage nurse as abusive, a regular attender, intoxicated or simply very dirty. The orthopaedic doctor or neurosurgeon may have a similar heartsink feeling when dealing with patients suffering chronic back pain or the general surgeon with the fully investigated female patient with abdominal pain. The sense of frustration may well translate as dislike for the patient. Although there is no agreement in the literature, there are some factors that can predispose patients to seem difficult.

Case study 1

Mrs T is an unemployed 42-year-old woman who joined Dr G’s list about a year ago. She is divorced and has two teenage children. Mrs T rings for an appointment at least three times per month. Her complaints tend to be different every time, ranging from abdominal pain to thrush, to flu symptoms; she has also attended several times with UTI-like symptoms, but her MSU has always been clear.

She has received several courses of antibiotics in the last few months for various problems. She sees a different doctor at the surgery every time. In her visits she often brings up different problems and her consultations tend to last longer than the allocated time. She often mentions medical problems that affect her children as well, and sometimes she attends with one of them and demands that the child is seen as well.

Dr G is about to start his morning clinic when he glances at the list of patients booked for today and notices Mrs T is on the list. His heart sinks. He knows she will complain of one or more of her many illnesses, will talk a lot and will not listen to a word he says, and then will demand treatment. There are already three emergencies booked on top of the usual list so the clinic will finish late. Dr G feels an immediate sense of frustration and even anger. He cannot avoid negative feelings towards Mrs T, which in turn make him feel guilty.

Tips on management

  • Ensure that the poly-symptomatic patient is not presenting with organic disease, being aware that at any point there might be underlying pathology.
  • Summarise the main concerns in your notes to facilitate the next consultation.
  • Set rules regarding frequency of routine consultations, eg, monthly consultations.
  • Be firm about one appointment for one patient.
  • Negotiate which problem to address in that day’s consultation.
  • Discuss with colleagues the reasons for repeated attendance and draw up a consistent plan of action in relation to the patient.
  • Acknowledge potential social issues.
  • Decide on thresholds for referrals and investigations.
  • Try to avoid using a prescription as a way of finishing the consultation.
  • Be empathetic and try to develop non-judgmental listening.
  • If at all possible, modify the scheduling system to allow more time for a difficult patient.
  • Empower the patient to stop taking the “child’s role”.

 

Case study 2

Emergency medicine junior doctor, Dr W, picks up the card of the next patient to be seen, Mr B. one of the nurses approaches him and comments that Mr B has been shouting at everyone since his arrival and complaining about the wait. Dr W sighs. He simply wishes he didn’t have to see that patient, as he knows the kind well.

Dr W enters the cubicle and introduces himself. He asks Mr B how he is feeling. Mr B remains slumped in his chair, complaining about how long he has had to wait. Dr W manages to ascertain that Mr B has come to the department suffering from epigastric pain. On being questioned about the number of units of alcohol he drinks per day, Mr B becomes agitated and abusive. He threatens to complain about Dr W. The history and examination continue. Mr B finally goes home with a diagnosis of gastritis and a prescription for Gaviscon. Dr W feels exhausted and irritated. He admits to himself that he has rushed the consultation to get the patient off his back and feels guilty.

Tips on management

  • Attempt an initial analysis of the possible reasons for the patient’s behaviour. Could there be a particular cause for anxiety or a previous catastrophic experience? 
  • Make a tactful assessment of the patient’s distress. 
  • Remain professional and polite, firm and direct, but calm. 
  • Avoid over-forcefulness and confrontation. 
  • Stay safe. If the patient becomes physically abusive, warn him that he might need to be removed. 
  • Be particularly comprehensive in your documentation. 
  • Try to stay focused on the medical complaint and manage investigations and treatment appropriately. 
  • Postgraduate training on management of anger, structured activities of reflection, such as keeping a journal, clinical incident analysis and mentoring could be helpful. 
  • Discussing your frustration with a senior colleague might be helpful in order to get back to the right mindset.

 

Case study 3

Dr Q’s next patient is 39-year-old Ms A. As she sees her name, Dr Q gets an immediate feeling of hopelessness. Ms A’s visits always fill her with despair. Ms A usually complains about general non-specific aches and tiredness, and very often back pain. Communication with Ms A is not straightforward due to her language skills and she has had a number of different investigations and referrals.

Ms A has a very negative view about what is done for her. She tries alternative therapies, but never finishes any of the medications prescribed for her at the surgery. She often attends in order to request certificates, as she misses so many days at work. Dr Q feels that no matter how hard she tries to help Ms A, nothing is ever enough.

Tips on management

  • Inform yourself of any cultural aspects of illness.
  • With prior consent, involving the family in the management of a difficult patient may be of value.
  • Be honest with the patient about diagnosis, treatments and unmet expectations. Review expectations regularly.
  • Show firm respect combined with a caring attitude.
  • Consider psychiatric input. Depression or anxiety might be an underlying condition. Use primary care psychiatric screening tools.
  • Discuss a management programme with the patient, including the patient’s own responsibilities.
  • Try to identify the patient’s expectations and goals and question them about compliance with treatments.
  • Make medication only one part of patient management.
  • Use your own method of relaxation before and after seeing the patient. A few deep breaths before seeing the next patient might be of help.

Advice from MPS

As frustrating as we may find such challenging patients to be, there is an important ethical and professional challenge to a doctor lurking in every difficult patient interaction

While challenging patients can consume large amounts of time and resources they are also at high risk of receiving less than ideal care, including unnecessary investigations, inappropriate treatments and of having serious pathology misdiagnosed or missed.

As frustrating as we may find such challenging patients to be, there is an important ethical and professional challenge to a doctor lurking in every difficult patient interaction. Difficult patients are really suffering. While as doctors we may be able to easily identify the source of their suffering in their particular behaviours and attitudes, and have a clear picture in our own mind of the steps they should take to overcome them, this does not negate the fact that the patient can still be suffering and in great distress.

If we are really to provide compassionate and ethical care, we need to remind ourselves that the vast majority of difficult patients have a level of suffering commensurate with the degree of frustration we experience. The techniques described in the cases above need to be utilised with a recognition of this fact and a genuine desire to ensure our care is professional and kindly. “Difficult” patients often have a history of significant dysfunction and personal rejection in their early life that may go some way to explaining their behaviours nd attitudes. If a doctor is able to recognise in some of these challenging patients the possibility that “there but for the grace of God go I”, then  compassionate and professional approach may come a little easier.

Learning to view difficult patients “as a challenge rather than a chore” is a good starting point.10 Developing effective interpersonal skills and an attitude that is open to considering the level of suffering the patient is experiencing, despite their difficult behaviour and attitudes, may be the best way for you to minimise that familiar heartsink feeling.

The classic four types of difficult patients

  • Dependent clingers – Repeated requests for attention, reassurance, urgent demands for explanation, affection and medication. 
  • Entitled demanders – Patients that exude an innate sense of deservedness; they use intimidation, devaluation, and guilt induction to place the doctor in the role of “the inexhaustible supply depot”.
  • Manipulative help-rejecters – Patients who return to the surgery again and again, almost smugly satisfied to report that, once again, the treatment or regimen hasn’t worked. Their pessimism appears to increase in direct proportion to the doctor’s effort and enthusiasm.
  • Self-destructive deniers – Appear to find their main pleasure in defeating the physician’s attempts to preserve their lives. This may represent a chronic form of suicidal behaviour.1

Elements that might contribute to a patient becoming difficult

Patient factors3

  • Unrecognised psychiatric disorders (eg, anxiety or depression) 
  • Somatisation 
  • Alcoholism 
  • Borderline personality disorder 
  • Previous experience of poor or disappointing care 
  • Well-founded need for information or in-built critical approach to problems 
  • Egotistic elements and an excessively demanding attitude.

Doctor factors

  • Strong assumptions as to how patients should behave and how medicine should be practised 4
  • Narcissism or arrogant personality5
  • Poor communication skills5
  • Poor psychosocial skills6
  • Cultural gaps6
  • Lack of experience6
  • Stress or overwork.7

Healthcare system factors7

  • Growing multicultural societies: communication problems and different or unrealistic expectations from doctors8
  • Increase of patient mistrust following high-profile cases
  • Pressure to reduce the cost of care and increase physician productivity decreasing the amount of time for consultations
  • Lack of continuity of care5
  • Easy access to wide-ranging, and sometimes confusing, information via modern technology.7

Criteria that might predispose a person to be a “heartsink”

  • Female preponderance
  • Over 40
  • Socially isolated, usually single, separated, widowed or with marital problems
  • Low tolerance for putting up with minor illnesses
  • Poor education and low social class
  • Poor insight
  • Concomitant serious illness
  • Experience of serious relationship dysfunction and rejection in early life.8

References

1. Groves, JE, Taking care of the hateful patient, The New England Journal of Medicine 298(16):883–7(1978)
2. Winnicott, DW: Hate in the countertransference, International Journal of Psychoanalysis 30:69–74 (1949)
3. Author’s discussions with “challenging patients”
4. Wilson, H, Reflecting on the difficult patient, Journal of the New Zealand Medical Association Vol 118 No1212 (2005)
5. Robinson, G et al, From medical student to junior doctor: The difficult patient Student BMJ 14:265–308 (2006)
6. D Steinmetz, H Tabenkin, The difficult patient as perceived by family physicians. Family Practice 18:495–500 (2001)
7. Haas, L et al, Management of the difficult patient, American Family Physician 72(10):2063–8 (2005)
8. Heartsink patients 
9. Mathers et al, Heartsink patients: a study of their general practitioner, Br J Gen Pract 45 (395):293–6 (1995)
10. Brown, S, Clinical Casebook – The frequent attender, Pulse Nov-07

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