From medical student to junior doctor: The “difficult patient”

Tough patients can cause doctors distress and can take up considerable amounts of time. Geoffrey Robinson and colleagues give advice on how to recognise and deal with these patients

Every doctor encounters patients who are frustrating and dissatisfying to look after. It has been estimated that these patients make up as much as 15% of our clinical practice. Junior doctors should recognise that although the “difficult patient” has multiple guises, the syndrome does exist, it is not uncommon, and certain management strategies and support are available to help.

The burden mostly lies with those providing long term care, something from which junior doctors are relatively protected owing to rotations throughout their training. However, difficult patients can engender avoidance by consultants responsible for their care, resulting in junior doctors bearing the load during admissions. This gives the junior doctor the opportunity to sort out the patient and enlighten the long suffering boss. Learning to recognise and manage the difficult patient is good training for general practice or specialist care.

It is also worth recognising that patients may sometimes encounter a “difficult doctor.” This is likely to occur if the doctor has the unfortunate characteristics of narcissism, arrogance, and poor communication skills.

Relating and working effectively with colleagues can also be difficult. Indeed, it is probably one of the most important skills to develop to ensure the satisfaction and survival of the junior doctor. However, that issue is not the focus of this review.

How do we recognise the difficult patient?

Understanding the difficult patient has come a long way since 1978, when Groves described them as “hateful patients” and proposed four distinct stereotypes: the dependent clinger, the entitled demander, the manipulative help rejecter, and the self destructive denier.

It is now recognised that they are a disparate class= group of patients with a wide range of characteristics and behaviours, of which only a few class= may be present in any one patient. Often, there is a degree of personality disorder or abnormal behaviour engendered by chronic physical illness. Seemingly the personality disorder may have gone unrecognised.

How does it affect the doctor?

Difficult patients have a common characteristic of causing doctors distress over a considerable period of time. Some patients behave in a way for which doctors are totally unprepared such as verbal abuse, harassment, and unfounded complaints. If doctors respond to a patient in a manner outlined in box 2, they are likely to be attending a difficult patient requiring particular care.

What is the source of the problem?

When dealing with a difficult patient the first thing to do is to identify the source of the problem. Is it primarily due to the patient, the doctor, or the patient-doctor relationship, or is it due to the healthcare system?

Labelling the patient as difficult assumes an ideal doctor and an ideal doctor-patient relationship working within an ideal system. This is rarely the case. Failures within the doctor can be simply the result of tiredness and overwork or insecurity due to inexperience. A lack of familiarity with personality disorders by junior doctors may well contribute to the problem.

Failures within the doctor-patient relationship include poor communication with the patient and not recognising what the patient wants. Difficulties may emanate from the junior doctor not recognising how the patient copes with his or her disease or not understanding what the disease means for the patient.

Problems within the healthcare system outside the control of the junior doctor may contribute. On the wards there may be a lack of attention or adequate time to spend with the patient because of excessive workload. In the outpatient department the doctor may be “on the back foot” from the start because of the clinic running late or previous appointments having been cancelled. Lack of continuity of care may be a problem in both the inpatient and outpatient setting as a result of shift work and multiple responsibilities.

What approaches can be taken?

Try always to respond with firm respect and caring and avoid bullying and confrontation. Psychiatric liaison can provide long overdue insight and guidance for management of these patients (and distressed clinicians) and can usually be obtained for inpatients in general hospitals. Discussion with peers may also be beneficial.

Attempting to set limits is important to prevent behaviours such as accosting staff, demanding nocturnal reviews or treatment changes, or leaving the ward. Similarly, a clearly communicated treatment plan is vital. This includes not only drug treatments (for example, precise dosage, frequency, and indication for as needed drugs), but also nursing and other clinical interventions. Treatment contracts may be necessary, but these agreements are not of legal standing. Invoking such an approach is time consuming but may be beneficial overall and worthwhile in the longer term. Box 3 lists some of the approaches that may be helpful to the junior doctor.

Remember to maintain your professionalism despite provocation and be particularly careful about your case notes, which are often accessed by this group of patients. None of these approaches is easy or necessarily successful. It is an unfortunate fact that difficult patients can take up considerable amounts of doctors' time. Learning how to deal with these situations can be time saving and can lead to a more rewarding and mutually beneficial relationship with the patient. Medicine has enough challenges, and difficult patients contribute appreciably to doctors' long term stress.

       

           

• Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883-7
• Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Reg Anesth Pain Med 2005;30:184-92
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• Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, et al. The difficult patient: prevalence, psychopathology and functional impairment. J Gen Intern Med 1996;11:1-8
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