Hospital Medicine

The difficult patient

I. Problem/Challenge.

We have all had encounters with 'the difficult patient' and 'we know one when we see one'. As many as 20% of patient encounters are rated as difficult by physicians in the outpatient setting. Much of our understanding of these patients is derived from the outpatient setting, as there is less data from the inpatient setting. There are no randomized trials to guide best practice for these encounters. The difficult patient is one whose behaviors do not conform to our expectations as health care providers. These patients may have multiple unrecognized medical, psychiatric, psychological and social issues all operant at the same time.

During the clinical encounter, diagnostic workup and development of the therapeutic strategy leading to a successful discharge from the hospital, physicians depend on the cooperation of the patient and 'buy-in' to the plan of care. When this collaboration fails to develop or breaks down then difficulties arise in the doctor-patient relationship - hence the Difficult Patient. These patients have been variously labeled as 'frustrating patients', 'heartsink patients', problem patients and difficult patients. They all have the unifying feature of provoking distress in the physician that is in excess of the expected difficulty of their clinical management.

Phenotype of the Difficult Patient:

  1. Manipulative, demanding and time consuming

  2. All knowing, often questioning clinical decisions and diagnostic strategies

  3. Non cooperative with history taking, non cooperative with medications

  4. Angry, frightened, defensive, belligerent, verbally abusive and/or combative with staff

  5. Refusal to leave the hospital when discharged or wants to leave Against Medical Advice

  6. May have multiple chronic medical complaints or brings a list of medical diagnoses

  7. May have frequent use of the health care system (multiple admissions)

  8. May have associated psychiatric illness or a pathologic personality disorder

Physician Response to the Difficult Patient:

  1. A feeling of resignation, anger or disgust

  2. Labeling (gomer, frequent flyer, etc)

  3. Become threatening to the patient

  4. Perfunctory or limited clinical evaluation and therapeutic plan (lack of caring)

  5. Avoidance of contact (shortened visits at the bedside)

II. Identify the Goal Behavior.

Encounters with difficult patients may develop into a contest of wills. The physician knows what is right for the patient, the patient is not accepting the plan and may even be overtly trying to suborn the plan. The most crucial first step in these encounters is a time out. Take a breath and try to address the concerns of the patient. Think through other causalities that may be contributory to the patients behavior. Rule out other possible etiologies:

  1. Metabolic derangement with acute delirium

  2. Drug related behaviors (adverse reaction to a medication, prior ingestion)

  3. Organic illness that may be contributory (syphilis, undiagnosed dementia, Korsakoff syndrome)

  4. Consider the real possibility of an underlying psychiatric illness or personality disorder contributing to the behavioral phenotype

III. Describe a Step-by-Step approach/method to this problem.

There is no prescribed path for dealing with a difficult patient. In the end it will require a composite of skills acquired through the course of the physicians clinical experience. These are primarily interpersonal skills, once other etiologies as listed above are ruled out.

  1. Do not get drawn into conflict. Frequent time outs from the confrontation may be useful.

  2. These encounters can be very time consuming and may need to be spaced out during the day, frequently revisiting the patient.

  3. Establish the context of the patient's fear or concern. This may require in-depth interviews about family issues, financial constraints, dispelling misperceptions that the patient may have developed about the medical care plan or just simple miscommunication. In any case these are the most difficult interviews which require close patient rapport, insightful questioning and attentive listening.

  4. Sitting at the edge of the bed in a passive open posture is often the first tool to addressing the concerns of a difficult patient.

  5. The use of reflective statements ("I can see why you might feel that way..") has been shown to be a powerful interviewing technique to defuse difficult encounters.

  6. If at any time the physician feels threatened by the encounter he/she should withdraw from the room and alert security and risk management. It may be necessary to return to the interview with an observer.

  7. At times the encounter will deteriorate to where there is no therapeutic relationship between the patient and the physician. In this case the physician should offer to transfer care to a colleague.

  8. At times the patient may 'fire' the physician. This should not be interpreted as a comment on the ability or integrity of the physician who has been fired. The decision should be discussed with the patient and if no resolution can be found, then a new physician should assume care.

  9. In some care settings these patients become a part of the fabric of the hospital. In these case it may be useful to develop a contractual relationship with the patient during admissions - Contracting For Acceptable Behaviors - much in th same way that one might contract for adherence to a smoking cessation program or scheduled insulin therapy in the outpatient. Discuss this option within your group and with Risk Management to see if this falls within the accepted scope of hospital policy.

IV. Common Pitfalls.

The most difficult part of the encounter with a difficult patient is that the behavior is seen as irrational and incomprehensible by the physician. It may be seen as an affront to the ego of the attending physician. The physician must not be drawn into a contest of wills and egos but will need to rather be humble in the face of the encounter. There is no value in dragging out the encounter past the point of no return. When the situation has deteriorated to the point of collapse of the therapeutic relationship then discuss it with your group and find a new physician for the patient.

V. National Standards, Core Indicators and Quality Measures.

No national standards/benchmarks established yet. However, I will note the growing recognition of physicians being scored on 'service excellence' in patient questionnaires as a performance quality measure. These data may become part of the physicians profile in the future so it behooves us to develop a toolbox of interviewing styles and other interventions to defuse these difficult patient encounters.

VI. What's the evidence?

Groves, JE. "Taking care of the hateful patient". N Engl J Med.. vol. 29. 1951. pp. 883-885.

Haas, LJ, Leiser, JP, Magill, MK, Sawyer, ON. "Management of the difficult patient". Am Fam Phys.. vol. 72. 2005. pp. 2063-2068.

Smith, S. "Dealing with the difficult patient". Post Grad Med J. vol. 71. 1995. pp. 653-657.

Steinmetz, D, Tabenkin, H.. "The difficult patient as perceived by the family physicians". Fam Pract.. vol. 18. 2001. pp. 495-500.

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