Glancing at your clinic schedule for the following day, you see that one of your most challenging patients is scheduled to arrive at 8:00 AM. mayThis patient has chronic medical and psychiatric issues, is abrasive and argumentative, and frequently demands more of your time than your other patients. You are concerned that tomorrow’s 20-minute appointment will last an hour, and you lose the remainder of the evening ruminating about it.
Patients like this one, whose prevalence may be as high as 20% in primary care populations, can generate conflict for physicians because of the ethical tension such patients create. Physicians may recognize their ethical obligation to serve all patients with unconditional regard and equanimity, but they may also find it challenging to work productively with such patients who may be persistently non-compliant, an emotional drain, hostile, or who seem to pull attention away from their other deserving patients. Addressing this tension is important not just because of its effect on the quality of patient care, but also to improve physician resilience.
First, a clarifying note about terminology. Although the literature historically described such patients as “difficult,” in the context of modern medical practice, this conception is increasingly problematic. Such a label is pejorative and subjective, non-standardized, and not designed to advance a patient’s care. Labels like “difficult” also draw attention away from the health care professional’s primary responsibility to provide care by putting the onus on the patient to change, and by encouraging the clinician to relinquish their professional responsibility for managing the challenges that arise in the patient’s care. It still takes “two to tango,” whenever there is conflict. For that reason, more accurate, objective, and patient-centered labels drawn from research on this population include, “difficult encounter,” “difficult patient-physician relationship,” and “difficult-to help.”1
How then should physicians manage these complicated relationships given their ethical obligations? Some broad principles are useful in empowering health care professionals to both promote the care of “difficult-to-help” patients as well as improve physician resilience in responding productively to clinically challenging encounters. These strategies include fostering intellectual curiosity about our own strong emotions in these interactions, cultivating empathy for patients, and setting appropriate limits when necessary.
First, clinicians are likely to have a range of strong feelings when working with these patients, some of which might interfere with their cognition or with developing empathy. This work required to identify, understand, and process the emotions that arise in clinical care is termed “emotional labor.” So before we can manage those emotions to ensure they do not unduly interfere with our ability to problem-solve, we have to recognize that we are having them. Even if physicians notice their heart racing or their neck stiffening when they become tense and angry, admitting to having anger can be difficult if they believe these emotions are considered unprofessional. However, a range of positive or negative emotions is a normal human response to any relationship, whether one is a health care professional or not. What differentiates health care professionals from others is not that they do not have emotions, but rather that their emotions should not unduly affect their professional behavior or judgment. Counting slowly to 5 or taking deep breaths can help maintain our cool and minimize the likelihood of becoming angry.
By managing these strong emotions, clinicians can more easily cultivate the intellectual curiosity necessary for good patient care and the development of empathy for the patient. As one author has written, many of these patients “come by their behavior honestly.”2 They are often struggling, in distress, and need help. Reframing the problem from that perspective can often help make for more productive work with these patients. Building these skills, while challenging, is important, as physicians without them may be 3 times more likely to rate such encounters as “difficult.”
Second, it is easy to take the patient’s behavior personally and conclude that the patient is deliberately behaving in a way to make the physician’s life more difficult. In fact, the patient’s behavior may be consistent across other providers, and even with others outside of the health care setting. Their behavior may also be part of their response to illness, and they may be functioning the only way they know how. By remembering what the patient brings to the encounter and by depersonalizing such behavior, it may be easier to cultivate curiosity and empathy for the patient.3
Finally, there may be a role for reasonable, fair, and consistent limit setting when patients display unsafe, disrespectful, or otherwise inappropriate behavior.4 Physicians are justified in expecting respectful interactions from patients, and they can set limits on patient’s behavior under appropriate clinical circumstances. For example, for patients who regularly demand more of their physician’s time, consistently keeping appointments to a pre-specified time and ending them at the allotted time is often reasonable for non-urgent matters. Working with trusted colleagues can help clinicians identify what kinds of limits are reasonable, how to maintain appropriate professional boundaries, and how best to ensure the patient continues to receive high quality care.
Even armed with such strategies, clinicians may still need support in caring for such “difficult-to-help” patients. The extra time and resources needed to maintain a therapeutic relationship is not always easy or straightforward. Furthermore, not every clinician has (or wants to develop) the skills needed to attend to the additional work in caring for these patients. For sure, that is the clinician’s choice. At a minimum though, reconceptualizing the “difficult patient” as the “difficult encounter” for what may be a sizeable minority of encounters intends to draw clinicians closer to their professional commitments and professional identify as healers. These are the important first steps to take, and a lofty goal for sure.
David J. Alfandre MD, MSPH, is a health care ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
1. Alfandre D. Reconceiving the relationship and supporting physician responsibility. Am J Bioeth 2012;12:9-11.
2. Kahn, MW. 2009. What would Osler do? Learning from “difficult” patients. New Engl J Med. 361: 442-443.
3. Dyche L, Epstein RM. Curiosity and medical education. Med Educ. 2011;45:663-668.
4. Sharrock J, Rickard N. Limit setting: A useful strategy in rehabilitation.” Aust J Adv Nurs.2002;19:21-26.